1548459266 NPI number — MEDICAL CLINIC OF MCALESTER, LLC

Table of content: (NPI 1548459266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548459266 NPI number — MEDICAL CLINIC OF MCALESTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL CLINIC OF MCALESTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548459266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1006
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCALESTER
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74502-1006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-423-5916
Provider Business Mailing Address Fax Number:
918-423-5967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 E DELAWARE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCALESTER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74501-5512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-423-5916
Provider Business Practice Location Address Fax Number:
918-423-5967
Provider Enumeration Date:
10/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ONARO
Authorized Official First Name:
NELSON
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
918-423-5916

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  3437 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100069700C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7048926 . This is a "CIGNA" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 158744003 . This is a "AR MEDICAID" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 610872700 . This is a "DOL" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 419909840001 . This is a "BC/BS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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